Implication of the presence of a variant hepatic artery during the Whipple procedure

Surgical and oncological implications of the presence of hepatic artery anatomical variations in patients undergoing pancreaticoduodenectomy: a single center experience

The presence of an aberrant right hepatic artery (a-RHA) could influence the oncological and postoperative outcomes after pancreaticoduodenectomy (PD). A comparative study was conducted, including patients who underwent PD with a-RHA or with normal RHA anatomy. The primary endpoints were R1 resection in all margins (pancreatic, anterior, posterior, superior mesenteric artery, and portal groove), overall survival (OS), and disease-free survival (DFS). The secondary endpoints were morbidity, mortality, biliary leak (BL), postoperative pancreatic fistula (POPF), delayed gastric emptying (DGE), post pancreatectomy hemorrhage (PPH), length of stay (LOS), and operative time (OT). The selection bias was measured using the d-value and limited using entropy balancing analysis. Patients with arterial variants were 84 (37.5%), 39 (17.4%) of whom had a-RHA from SMA. The patients with a-RHA were more frequently symptomatic (d = 0.652), often affected by PDAC (d = 0.369), and judged borderline resectable (d = 0.588). Neoadjuvant therapy was more frequently proposed for patients with a-RHA (d = 0.465). The patients with a-RHA often had the Wirsung dilated compared to those without a-RHA (d = 0.336). After bias correction, the R1 resection rate on the superior mesenteric artery (SMA) margin was higher in the a-RHA group than in patients with normal RHA anatomy (OR 2.3; 1.1-5.2; P = 0.045). OS, DFS, morbidity, mortality, biliary leak (BL), postoperative pancreatic fistula (POPF), delayed gastric emptying (DGE), post pancreatectomy hemorrhage (PPH), length of stay (LOS), and operative time (OT) were similar in unmatched and matched population. The presence of a-RHA seems to increase the risk of R1 resection in the SMA margin.

Preoperative Identification and Outcomes of Vascular Variants on Surgery for Chronic Pancreatitis

INTRODUCTION

Surgeries for chronic pancreatitis are tailored based on disease process and either include parenchymal-preserving surgeries or total pancreatectomy with or without islet cell autotransplantation. It is critical to account for vascular variants as injuries to these are associated with short- and long-term morbidity and mortality. There is a lack of contemporary data on the true incidence of aberrant arterial anatomy, and it is likely to be underreported by nonhepatobiliary radiologists.

METHODS

This study is a retrospective analysis of all patients undergoing pancreatic resections for chronic pancreatitis at the single center. The presence of vascular variants was compared between standard reporting and preoperative imaging review by a hepatobiliary radiologist and surgeon. Primary outcomes were operative time and blood loss.

RESULTS

Of the 72 pancreatic resections for chronic pancreatitis, 50 (69%) satisfied inclusion criteria. Three of fifty (6%) had vascular anomalies reported on standard reporting while 11 (22%) had vascular anomalies identified on preoperative imaging review and confirmed at surgery. Hence, only 27% of patients with variant vascular anatomy were reported on standard imaging. There was no significant difference in operative times or blood loss between those with and without known vascular anomalies.

CONCLUSIONS

Pancreatic resection is a complex undertaking as long-standing inflammation distorts anatomic planes and increases opportunity for inadvertent vascular injury especially if there are aberrant vessels. In this study, we found that anatomic vascular variants are oftentimes not reported. Dedicated surgical planning with review of cross-sectional imaging identified all cases of anatomic variants resulting in no difference in operative time or incidence of intraoperative hemorrhage.

The Presence of an Aberrant Right Hepatic Artery Did Not Influence Surgical and Oncological Outcomes After Pancreaticoduodenectomy: A Comprehensive Systematic Review and Meta-Analysis

BACKGROUND

The presence of an aberrant right hepatic artery (a-RHA) could influence the oncological and postoperative results after pancreaticoduodenectomy (PD).

METHODS

A systematic review and metanalysis were conducted, including all comparative studies having patients who underwent PD without (na-RHA) or with a-RHA. The results were reported as risk ratios (RRs), mean differences (MDs), or hazard ratios (HRs) with 95% confidence intervals (95 CI). The random effects model was used to calculate the effect sizes. The endpoints were distinguished as critical and important. Critical endpoints were: R1 resection, overall survival (OS), morbidity, mortality, and biliary fistula (BL). Important endpoints were: postoperative pancreatic fistula (POPF), delayed gastric emptying (DGE), post pancreatectomy hemorrhage (PPH), length of stay (LOS), and operative time (OT).

RESULTS

Considering the R1 rate no significant differences were observed between the two groups (RR 1.06; 0.89 to 1.27). The two groups have a similar OS (HR 0.95; 0.85 to 1.06). Postoperative morbidity and mortality were similar between the two groups, with a RR of 0.97 (0.88 to 1.06) and 0.81 (0.54 to 1.20), respectively. The biliary fistula rate was similar between the two groups (RR of 1.09; 0.72 to 1.66). No differences were observed for non-critical endpoints.

CONCLUSION

The presence of a-RHA does not affect negatively the short-term and long-term clinical outcomes of PD.

Clinical significance of variant hepatic artery in pancreatic resection: A comprehensive review

The anatomical structure of the pancreaticoduodenal region is complex and closely related to the surrounding vessels. A variant of the hepatic artery, which is not a rare finding during pancreatic surgery, is prone to intraoperative injury. Inadvertent injury to the hepatic artery may affect liver perfusion, resulting in necrosis, liver abscess, and even liver failure. The preoperative identification of hepatic artery variations, detailed planning of the surgical approach, careful intraoperative dissection, and proper management of the damaged artery are important for preventing hepatic hypoperfusion. Nevertheless, despite the potential risks, planned artery resection has become acceptable in carefully selected patients. Arterial reconstruction is sometimes essential to prevent postoperative ischemic complications and can be performed using various methods. The complexity of procedures such as pancreatectomy with en bloc celiac axis resection may be mitigated by the presence of an aberrant right hepatic artery or a common hepatic artery originating from the superior mesenteric artery. Here, we comprehensively reviewed the anatomical basis of hepatic artery variation, its incidence, and its effect on the surgical and oncological outcomes after pancreatic resection. In addition, we provide recommendations for the prevention and management of hepatic artery injury and liver hypoperfusion. Overall, the hepatic artery variant may not worsen surgical and oncological outcomes if it is accurately identified pre-operatively and appropriately managed intraoperatively.

Conjoined right hepatic artery from branches of the common hepatic and gastroduodenal arteries: a rare anatomic variant

PURPOSE

To describe a previously unreported anatomical variant of the hepatic arterial supply: a conjoined right hepatic artery, formed by branches of the common hepatic artery and gastroduodenal artery.

METHOD

A 54-year-old female with oligometastatic colorectal cancer with metastases to the liver presented for planning stage arteriography in preparation for Y90 radioembolization.

RESULTS

Arteriography of the common hepatic artery demonstrated bifurcation into a right hepatic artery and gastroduodenal artery. The gastroduodenal artery gave rise to a proximal branch, from which the left hepatic artery originated and then continued to anastomose in the hilum of the liver to the right hepatic artery originating from the common hepatic artery. It was initially identified on visceral artery arteriography and then retrospectively recognized on pre-procedural CT scan.

CONCLUSION

Anatomical variants of the hepatic arterial supply are important to recognize during planning stage arteriography in preparation for Y90 radioembolization. Knowledge of these variants is also important for pre-operative planning.

Dealing with hepatic artery traumas: A clinical literature review

BACKGROUND

The hepatic artery (HA) is one of the most threatened vascular structures during hepatopancreatobiliary (HPB) surgeries and interventional procedures. It can be affected by many clinical pictures, especially tumors, due to its anatomical position and neighborhood.

AIM

To reveal the evolution and recent developments in the management of HA traumas in the light of the literature.

METHODS

In this article, 100 years of MEDLINE (PubMed) literature and articles including cases and series of HA injuries were reviewed, and the types of injury occurrence, treatment, and related complications and their management were compiled.

RESULTS

The risk of HA injury increases during cholecystectomies and pancreatoduodenectomies, among the most common operations. HA anatomy shows anomalies in approximately 15%-25% of the cases, further increasing this risk. The incidence of HA injury is not precisely known. Approaches that have evolved in recent years in managing patients with HA injury (laceration, transection, ligation, resection) with severe morbidity and mortality risk are reviewed in light of the current literature.

CONCLUSION

In conclusion, complications and deaths due to HA injury are less common today. The risk of complications increases in patients with hemodynamic instability, jaundice, cholangitis, and sepsis. Revealing the variations in the preoperative radiological evaluation will reduce the risks. In cases where HA injury is detected, arterial flow continuity should be tried to maintain with primary anastomosis, arterial transpositions, or grafts. In cases where bile duct injury develops, patients should be directed to HPB surgery centers, considering the possibility of accompanying HA injury. Large-scale and multicentric studies are needed to understand better the early and long-term results of HA ligation and determine preventive procedures.

Anatomic Variations of the Hepatic Artery in 5625 Patients

Purpose

To analyze the origin and anatomic course of the hepatic arteries by using digital subtraction angiography (DSA) and multidetector CT in a large study sample.

Materials and Methods

This retrospective study included 5625 patients who underwent liver CT and chemoembolization between January 2005 and December 2018 (mean age, 60 years ± 11 [range, 11-99 years]; 4464 males). The CT and DSA images were reviewed to evaluate the visceral arterial anatomy for variations in the celiac axis and hepatic arteries. Aberrant right hepatic arteries (aRHAs) and aberrant left hepatic arteries (aLHAs) were defined on the basis of their origin and anatomic course. Statistical analyses were performed to evaluate the association between aRHAs and aLHAs and the association between variations in the hepatic artery and celiac axis.

Results

Right hepatic arteries were categorized as being aRHAs (if originating from the proximal to middle common hepatic artery, gastroduodenal artery, superior mesenteric artery [SMA], celiac axis, aorta, splenic artery, or left gastric artery [LGA]) or as being aLHAs (if arising from the LGA, celiac axis, aorta, or SMA). The prevalence of aRHAs (15.63%; 879 of 5625) and the prevalence aLHAs (16.32%; 918 of 5625) were similar. Patients with an aRHA were more likely to have an aLHA than those without an aRHA (29.01% vs 13.97%; P < .001), and patients with an aLHA were more likely to have an aRHA than those without an aLHA (27.78% vs 13.26%; P < .001). There was no association between the hepatic arterial variations and celiac axis variations. A hypothetical anatomic model summarizing the observed variations was created.

Conclusion

A comprehensive list of hepatic arterial variations and a three-dimensional hypothetical model for the observed variations were described.Keywords: CT, Angiography, Liver, Anatomy, Arteries© RSNA, 2021 Supplemental material is available for this article. See also commentary by Sutphin and Kalva in this issue.

Hepatic vascular anomalies during totally laparoscopic pancreaticoduodenectomy: challenging the challenge

The presence of hepatic vascular anomalies may add challenges to an already difficult surgery such as pancreatoduodenectomy, particularly when performed laparoscopically. Thus, our aim was to assess the impact of an aberrant right hepatic artery (aRHA) on postoperative outcomes during laparoscopic pancreatoduodenectomy (LPD) . Data of patients who underwent LPD were prospectively gathered and retrospectively analyzed. Patients with types III, IV, VI, VII, VIII, and IX anomalies according to Michels' classification were included in the aRHA group and were compared with the remaining patients (nRHA group). 72 patients underwent LPD; 14 of these had an aRHA (19.4%). Except for BMI (p = 0.021), the two groups did not differ in terms of clinico-pathological characteristics. The two groups had similar postoperative complications (p = 0.123), pancreatic fistula (p = 0.790), biliary leakage (p = 0.209), postpancreatectomy hemorrhage (p = 0.790), reoperations (p = 0.416), and mortality (p = 0.312). The median number of lymph nodes harvested was higher in aRHA group (p = 0.032), while R0 resection rate was similar between groups (p = 0.635). At the multivariate analysis, only moderate/high FRS (OR 3.95, p = 0.039) was an independent predictor of postoperative complications. This study suggests that aRHA has no negative impact on surgical and oncological outcomes in patients undergoing LPD.

Prepancreatic common hepatic artery arising from superior mesenteric artery: an exceptional but important finding during pancreaticoduodenectomy

PURPOSE

The hepato-mesenteric trunk is an extremely rare condition in which the common hepatic artery (CHA) originates from the superior mesenteric artery (SMA). Usually, CHA passes behind the head of the pancreas. A systematic review was performed to provide guidelines for the perioperative management of patients with this anatomical variation who underwent a pancreaticoduodenectomy (PD). A case report was also included.

METHODS

A systematic search of the literature was conducted and the manuscript was structured following point-by-point the PRISMA guidelines. The risk of bias within individual studies was assessed using the Joanna Briggs Institute Critical Appraisal Checklist tools. Case report was structured according to the CARE guidelines.

RESULTS

After an initial selection of 141 titles, 9 articles were included in the study (n = 10 patients). A postoperative surgical complication which required a reintervention occurred only one time. In four patients, CHA had a posterior position relative to pancreas, while in three cases, it was anterior. The remaining three patients had an intrapancreatic course. The CHA was resected in two patients, with an end-to-end reconstruction or using the splenic artery stump. In only three patients, a preoperative multidisciplinary presentation was performed and in four cases, the CHA variation was not described by radiologists in formal CT-scan reports.

CONCLUSION

Although there are no definitive guidelines, improvements in the preoperative knowledge of such a rare anatomical variation may ensure better postoperative outcomes, avoiding intraoperative accidents and life-threatening postoperative complications.

Aberrant gastroduodenal and proper hepatic arteries

PURPOSE

Anatomic variants of the celiac trunk and superior mesenteric artery are common, thus knowledge of these variants is important for preoperative planning of abdominal surgery and interventional procedures.

METHODS

We report a rare anatomic variant of replaced proper hepatic and gastroduodenal arteries discovered upon CT angiography and diagnostic angiogram.

RESULTS

Emergent angiogram performed on a 61-year-old male who presented with signs and symptoms of upper gastrointestinal hemorrhage revealed a rare variant of an absent common hepatic artery and its branches with aberrant origins. The replaced proper hepatic artery originated from the superior mesenteric artery and the replaced gastroduodenal artery originated from a gastrosplenic trunk.

CONCLUSION

This case emphasizes the importance of evaluating preoperative imaging to identify vascular variants prior to undergoing abdominal surgery or interventional procedures.

Does Aberrant Right Hepatic Artery Influence the Surgical Short- and Long-term Outcome of Pancreatoduodenectomy?

BACKGROUND

Variations in vascular anatomy in pancreaticoduodenectomy for adenocarcinoma of the pancreatic head, aberrant right hepatic artery (αRHA) being the most frequent, may influence oncological outcome, surgical complexity, intra- and postoperative complications, and overall 5-year disease-free and survival rates.

MATERIALS AND METHODS

Between January 1988 and January 2018, 297 consecutive patients underwent pancreaticoduodenectomy at our Institutions and were divided into two groups: Group 1 patients were affected with αRHA; group 2 were without this vascular anomaly. The groups were retrospectively compared to identify differences in preoperative characteristics and intraoperative course, postoperative morbidity and mortality and long-term disease-free interval and overall survival. Cox regression analysis was used to investigate the role of variables statistically significant at univariate analysis in the short- and long-term outcomes.

RESULTS

Overall 44 (15%) patients had αRHA. No differences in patient characteristics were reported. The mean operative time was 451±58 minutes for group 1 and 317±27 minutes for group 2 (p<0.001), whereas mean blood losses were 729±488 ml and 508±119 ml, respectively (p<0.001). Group 1 patients had a longer stay in intensive care when compared to patients of group 2 (mean 5±2 versus 4±2 days, respectively; p<0.001). Furthermore group 1 patients had a significant longer hospitalization when compared to those of group 2 (mean 17±5 versus 15±3 days, respectively; p<0.006). No other significant differences were observed between the two groups. Cox regression analysis showed that independently of the presence of αRHA, the factors negatively affecting the 5-year survival rate were blood loss (p<0.001) and length of stay in intensive care (p<0.001).

DISCUSSION

αRHA increases the surgical complexity of pancreatoduodenectomy, negatively affecting intraoperative blood loss, length of operation, length in intensive care and hospitalization, but does not influence long-term survival and disease-free rates.